Meta-analysis of prophylactic mesh to prevent parastomal hernia

Effects of different mesh materials on complications after prophylactic placement for stoma formation: a systematic review and network meta-analysis

PURPOSE

We primary aimed to synthesise the available data, assess the effectiveness of different mesh materials in prophylactic mesh placement, and rank these materials according to the incidence of parastomal hernia (PSH) and other stoma complications.

METHOD

This network meta-analysis performed a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Four databases were searched for randomised controlled trials of prophylactic mesh placement. The aggregated results were performed in the STATA routine for Bayesian hierarchical random effects models.

RESULT

Thirteen randomised controlled trials from 1203 articles, met the inclusion criteria, including 681 cases without meshes, 65 cases with mesh material of xenogeneic acellular dermis (porcine/bovine), 27 cases with polypropylene/PG910, 114 cases with polypropylene/polyglecaprone (Monocryl), 117 cases with polypropylene/cellulose (ORC), 233 cases with polypropylene, and 35 cases with polypropylene/PVDF. In network A, compared with no mesh, only polypropylene (RR 0.24, 95% CI 0.04-0.80) were significantly associated with a reduction in the incidence of PSH. In network B, no statistical difference regarding stoma complications was found between mesh and no mesh.

CONCLUSION

Based on the network meta-analysis and ranking results, the polypropylene mesh material exhibited the best performance. However, this conclusion needs to be confirmed with larger sample sizes and high-quality randomised controlled trials.

Occurrence and prevention of incisional hernia following laparoscopic colorectal surgery

Among minimally invasive surgical procedures, colorectal surgery is associated with a notably higher incidence of incisional hernia (IH), ranging from 1.7% to 24.3%. This complication poses a significant burden on the healthcare system annually, necessitating urgent attention from surgeons. In a study published in the World Journal of Gastrointestinal Surgery, Fan et al compared the incidence of IH among 1614 patients who underwent laparoscopic colorectal surgery with different extraction site locations and evaluated the risk factors associated with its occurrence. This editorial analyzes the current risk factors for IH after laparoscopic colorectal surgery, emphasizing the impact of obesity, surgical site infection, and the choice of incision location on its development. Furthermore, we summarize the currently available preventive measures for IH. Given the low surgical repair rate and high recurrence rate associated with IH, prevention deserves greater research and attention compared to treatment.

Management of adult intestinal stomas: The 2023 French guidelines

AIM

Digestive stoma are frequently performed. The last French guidelines have been published twenty years ago. Our aim was to update French clinical practice guidelines for the perioperative management of digestive stoma and stoma-related complications.

METHODS

A systematic literature review of French and English articles published between January 2000 and May 2022 was performed. Only digestive stoma for fecal evacuation in adults were considered. Stoma in children, urinary stoma, digestive stoma for enteral nutrition, and rare stoma (Koch, perineal) were not included.

RESULTS

Guidelines include the surgical landmarks to create digestive stoma (ideal location, mucocutaneous anastomosis, utility of support rods, use of prophylactic mesh), the perioperative clinical practice guidelines (patient education, preoperative ostomy site marking, postoperative equipment, prescriptions, and follow-up), the management of early stoma-related complications (difficulties for nursing, high output, stoma necrosis, retraction, abscess and peristomal skin complications), and the management of late stoma-related complications (stoma prolapse, parastomal hernia, stoma stenosis, late stoma retraction). A level of evidence was assigned to each statement.

CONCLUSION

These guidelines will be very useful in clinical practice, and allow to delete some outdated dogma.

The clinical applications of D-type parastomal hernia repair surgery

OBJECTIVE

This study investigated the use of a modified laparoscopic repair of paraostomy hernia technique, called "D-Type parastomal hernia repair surgery" which combines abdominal wall and extraperitoneal stoma reconstruction, in patients with parastomal hernia (PSH) following colorectal stoma surgery. The aim was to determine whether D-type parastomal hernia repair surgery is a promising surgical approach compared to the traditional laparoscopic repair technique (Sugarbaker method) for patients with PSH.

METHODS

PSH patients were selected and retrospectively divided into two groups: the study group underwent D-type parastomal hernia repair, while the control group underwent laparoscopic Sugarbaker repair. Clinical data from both groups were analyzed.

RESULT

Compared to control group (n = 68), the study group undergoing D-type stoma lateral hernia repair had significant increase in total operative time (98.82 ± 12.37 min vs 124.61 ± 34.99 min, p < 0.001). The study group also showed better postoperative stoma bowel function scores in sensory ability, frequency of bowel movements, and clothing cleanliness without a stoma bag (p = 0.037, 0.001, 0.002). The treatment cost was significantly higher in the control group (3899.97 ± 260.00$ vs 3215.91 ± 230.03$, p < 0.001). The postoperative recurrence rate in the control group was 26.4%, while in the study group, it was 4.3%, with a significant statistical difference (p = 0.024). In terms of long-term postoperative complications, the study group had an overall lower incidence compared to the control group (p = 0.035). Other parameters showed no significant differences between the two groups.

CONCLUSION

The study suggests that D-type parastomal hernia repair surgery is a safe and feasible procedure. Compared to traditional surgery, it can reduce the recurrence of lateral hernia, improve postoperative stoma bowel function, and save medical resources.

Prophylactic mesh does not prevent parastomal hernia in long-term: Meta-analysis and trial sequential analysis

BACKGROUND

Previous randomized clinical trials, systematic reviews, and meta-analyses evaluating parastomal hernia prevention with mesh placement during end colostomy formation have reported contradictory results. This review aimed to assess the efficacy of this strategy in long-term follow-up according to the latest available data.

METHODS

Medline, EMBASE, Cochrane Library, Web of Science, and Google Scholar were searched. Randomized clinical trials were included if they compared mesh with no mesh during initial end colostomy creation in adult patients to prevent parastomal hernia with a follow-up longer than 2 years. A meta-analysis was performed to evaluate parastomal hernia incidence (primary outcome), parastomal hernia repair rate, and mortality. Subgroup analysis included surgical approach and mesh position, and trial sequential analysis was performed.

RESULTS

Eight randomized clinical trials involving 537 patients met the inclusion criteria. Based on long-term follow-up, the incidence of parastomal hernia was not reduced when a prophylactic mesh was placed (relative risk = 0.68 [95% confidence interval:0.46-1.02]; I2 = 81%, P =.06). The parastomal hernia repair rate was low; however, no difference was found between the groups (relative risk = 0.90 [95% confidence interval:0.51-1.56]; I2 = 0%; P = .70), and no difference was detected between the groups when mortality was assessed (relative risk = 1.03 [95% confidence interval: 0.77-1.39]; I2 = 21%; P = .83). Subgroup analyses did not show differences according to the surgical approach or mesh position used. Regarding trial sequential analysis, an optimal information size was not achieved.

CONCLUSION

Prophylactic mesh placement during end colostomy formation does not prevent parastomal hernia in the long term. The parastomal hernia repair rate and mortality rate did not vary between the included groups. Heterogeneity among the included randomized clinical trials might restrict the reliability of the results.

Surgical management of ostomy complications: a MISSTO-WSES mapping review

BACKGROUND

The creation of an ileostomy or colostomy is a common surgical event, both in elective and in emergency context. The main aim of stoma creation is to prevent postoperative complications, such as the anastomotic leak. However, stoma-related complications can also occur and their morbidity is not negligible, with a rate from 20 to 70%. Most stomal complications are managed conservatively, but, when this approach is not resolutive, surgical treatment becomes necessary. The aim of this mapping review is to get a comprehensive overview on the incidence, the risk factors, and the management of the main early and late ostomy complications: stoma necrosis, mucocutaneous separation, stoma retraction, stoma prolapse, parastomal hernia, stoma stenosis, and stoma bleeding.

MATERIAL AND METHODS

A complete literature research in principal databases (PUBMED, EMBASE, SCOPUS and COCHRANE) was performed by Multidisciplinary Italian Study group for STOmas (MISSTO) for each topic, with no language restriction and limited to the years 2011-2021. An international expert panel, from MISSTO and World Society of Emergency Surgery (WSES), subsequently reviewed the different issues, endorsed the project, and approved the final manuscript.

CONCLUSION

Stoma-related complications are common and require a step-up management, from conservative stoma care to surgical stoma revision. A study of literature evidence in clinical practice for stoma creation and an improved management of stoma-related complications could significantly increase the quality of life of patients with ostomy. Solid evidence from the literature about the correct management is lacking, and an international consensus is needed to draw up new guidelines on this subject.

The same parastomal hernia repairs rate in the different approaches to colostomy

PURPOSE

This study aimed to compare the parastomal hernia repairs rate in the different approaches to colostomy and investigate the risk factors for parastomal hernia formation in patients with permanent colostomies.

METHODS

Consecutive rectal cancer patients who underwent abdominoperineal resection from June 2014 to July 2020 in West China Hospital were divided into two groups according to their surgical approach for permanent colostomies. The impact of different approaches to colostomy on parastomal hernia repairs was determined by comparing a group of patients receiving an extraperitoneal route to colostomy with a group receiving transperitoneal. Potential variables were evaluated first with univariate and then multivariate analyses to identify the risk factors for the formation of parastomal hernia.

RESULTS

Two hundred two subjects in the transperitoneal group and 103 in the extraperitoneal group attended the follow-up visit with a median follow-up period of 33 (25th-75th percentiles, 17-46) months. Clinically and radiologically detectable parastomal hernias were present in 76 of 202 (37.6%) and 14 of 103 (13.6%) subjects in the transperitoneal and extraperitoneal groups during the follow-up period (p＜0.01). Besides, 10 of 76 (13.1%) subjects in the transperitoneal group and 2 of 14 (14.3%) subjects in the extraperitoneal group underwent a parastomal hernia operation during the follow-up (p = 0.82). In addition, the transperitoneal approach of colostomy (p = 0.002), older age (p＜0.001), and higher body mass index (p = 0.013) were identified as independent risk factors for the occurrence of parastomal hernia.

CONCLUSIONS

Extraperitoneal colostomy decreased the detectable parastomal hernias but did not reduce the surgical repair rate of parastomal hernias.

Prophylactic effect of retromuscular mesh placement during loop ileostomy closure on incisional hernia incidence-a multicentre randomised patient- and observer-blind trial (P.E.L.I.O.N trial)

BACKGROUND

Incisional hernia is a frequent complication following loop ileostomy reversal. Incisional hernias are associated with morbidity, loss of health-related quality of life and costs and warrant the investigation of prophylactic measures. Prophylactic mesh implantation at the time of surgical stoma reversal has shown to be a promising and safe method to prevent incisional hernias in this setting. However, the efficacy of this method has not yet been investigated in a large multicentre randomised-controlled trial (RCT) with adequate external validity. The P.E.L.I.O.N. trial will evaluate the efficacy of prophylactic mesh reinforcement after loop ileostomy closure in decreasing the rate of incisional hernia versus standard closure alone.

METHODS

P.E.L.I.O.N. is a multicentre, patient- and observer-blind RCT. Patients undergoing loop ileostomy closure will undergo intraoperative 1:1 randomisation into either abdominal wall closure with a continuous slowly absorbable suture in small-stitch technique without mesh reinforcement (control group) or abdominal wall closure with an additional reinforcement with a retromuscular non-absorbable, macro-pore (pore size ≥ 1000 μm or effective porosity >0%) light-weight monofilament or mixed structure mesh. A total of 304 patients (152 per group) will need to be randomised in the study. Based on inclusion and exclusion criteria, 1,014 patients are expected to be screened for eligibility in order to recruit the necessary number of patients. The primary endpoint will be the frequency of incision hernias within 24 months according to the European Hernia Society definition. Secondary endpoints will be the frequency of surgical site occurrences (including surgical site infections, wound seromas and hematomas, and enterocutaneous fistulas), postoperative pain, the number of revision surgeries and health-related quality of life. Safety will be assessed by measuring postoperative complications ≥ grade 3 according to the Dindo-Clavien classification.

DISCUSSION

Depending on the results of the P.E.L.I.O.N. trial, prophylactic mesh implantation could become the new standard for loop ileostomy reversal.

TRIAL REGISTRATION

DRKS00027921, U1111-1273-4657.

Has network meta-analysis resolved the controversies related to bowel preparation in elective colorectal surgery?

AIM

There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs.

METHOD

A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines.

RESULTS

Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options.

CONCLUSION

While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.

A Modified Surgical Technique to Prevent Parastomal Hernia

An extraperitoneal colostomy is not sufficiently effective in preventing parastomal hernias. On the basis of anatomic structures and mechanical principles, we modified this surgical technique by preserving the integrity of the posterior rectus abdominis sheath to prevent parastomal hernia, and we applied it clinically.

Cost Effectiveness of the Use of Prophylactic Mesh To Prevent Parastomal Hernia After Urinary Diversion with an Ileal Conduit

Background

Prophylactic lightweight mesh in the sublay position reduced the cumulative incidence of parastomal hernia (PSH) after cystectomy with ileal conduit diversion in a randomised controlled trial.

Objective

To investigate whether the use of prophylactic mesh is cost-effective in comparison to no mesh from the health care provider perspective.

Design, setting, and participants

Data on health care resource utilisation (outpatient care and inpatient care) were obtained for 159 patients included in a randomised trial. The patients underwent surgery at Skåne University Hospital or Helsingborg County Hospital (80 with a prophylactic mesh and 79 without) and information about care was ascertained from the regional health care register. The patients underwent surgery between 2012 and 2017 and were followed until death or August 2020.

Outcome measurements and statistical analyses

The primary outcome measure was the clinical incidence of PSH. Costs are reported in Euro in 2020 prices (€1 = 10.486 Swedish Krona) and presented as the incremental cost-effectiveness ratios (ICERs) with confidence intervals (CIs) calculated using a nonparametric bootstrap procedure. Sensitivity analyses and subgroup analyses were performed to capture the uncertainty for ICERs.

Results and limitations

The mean difference in total costs between the mesh and no-mesh groups was −€2047 (95% CI −€16 441 to €12 348). Seventeen patients (21.5%) in the no-mesh group developed clinical PSH versus six patients (7.5%) in the mesh group (p = 0.001). This indicates that mesh is less costly and more effective compared to no mesh from the health care provider perspective. Subgroup analyses showed that results were more advantageous for women and for patients younger than 71 yr and with less comorbidity than for their counterparts.

Conclusions

The use of prophylactic mesh during ileal conduit reconstruction to prevent PSH is cost-effective from the health care provider perspective.

Patient summary

In patients having their bladder surgically removed, a mesh implant can be inserted when a portion of the intestine is used to create an opening to drain urine from the body. Our results show that mesh use to prevent development of a hernia at the opening where urine exits the body is cost-effective from the perspective of health care providers.

The risk of inguinal hernia repair after radical prostatectomy - a population-based cohort study

OBJECTIVES

A nationwide population-based register study will evaluate the risk of postoperative inguinal hernia repair after primary curative-intent treatment of prostate carcinoma (PCa).

BACKGROUND

Several previous studies have suggested an increased risk of inguinal hernia repair after prostatectomy. Only a few studies have compared the risk by PCa treatment modalities.

METHODS

Data were collected between the years 1998 and 2016 from the national hospital discharge database HILMO and between the years 1998 and 2015 from the Finnish cancer registry to identify all men with prostate cancer with data on primary treatment available and information on inguinal hernia diagnoses and procedures among them. The risk of inguinal hernia repair among men managed with prostatectomy was compared to those treated with radiation therapy. Participants treated with prostatectomy were analyzed as a whole and separately stratified into subgroups managed with mini-invasive or open surgery. Multivariate Cox regression with adjustment for age and comorbidities was used for analysis.

RESULTS

A total of 7207 cases of PCa were included in the study. 4595 men were treated with radical prostatectomy and 2612 with radiation therapy. Overall, the risk of hernia repair was higher among men treated with prostatectomy compared to men who received radiation therapy as the primary PCa treatment (HR 1.42, 95% CI 1.14-1.77). The risk did not differ markedly by the prostatectomy method.

CONCLUSION

Prostate cancer treatment with prostatectomy is associated with an increased risk of inguinal hernia surgery than external beam radiation therapy treatment. This risk should be taken into account when planning PCa treatment.

Prophylactic Mesh for Prevention of Parastomal Hernia Following End Colostomy: an Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate the efficacy of prophylactic mesh placement during end colostomy formation at reducing rates of parastomal hernia using the most recently available data.

BACKGROUND

Systematic reviews and meta-analyses of randomized controlled trials (RCTs) have uniformly concluded that the use of prophylactic surgical mesh when fashioning an end colostomy reduces the risk of parastomal hernia. However, recent RCTs have failed to corroborate these findings. This study was designed to provide an updated systematic review and meta-analysis evaluating the efficacy of prophylactic mesh placement during end colostomy formation.

METHODS

A search of Medline, EMBASE, and CENTRAL was performed. Articles were included if they were RCTs that compared the use of prophylactic mesh to no prophylactic mesh during construction of an end colostomy following colorectal resection for benign or malignant disease. The primary outcome was parastomal hernia rate. A pairwise meta-analysis was performed using inverse variance random effects.

RESULTS

From 1,089 citations, 12 RCTs with 581 patients having prophylactic mesh placement and 671 patients not having prophylactic mesh placement met inclusion criteria. Incidence of parastomal hernia was significantly reduced in patients receiving prophylactic mesh (OR 0.60, 95% CI 0.46 to 0.80, p = 0.0003, I² = 74%). Results were no longer significantly different when only studies conducted in the last 5 years were analyzed (p = 0.10). There was no significant difference in postoperative morbidity, postoperative mortality, colostomy-specific morbidity, or length of stay between groups.

CONCLUSIONS

There remains a significant reduction in the risk of parastomal hernia with the use of prophylactic mesh at the time of end colostomy formation, despite recent evidence suggesting no difference. Further contemporary trials with the application of modern surgical technology are required.

Synthetic Mesh in Contaminated Abdominal Wall Surgery: Friend or Foe? A Literature Review

INTRODUCTION

The use of synthetic mesh in contaminated fields is controversial. In the last decade, published data have grown in this matter suggesting favorable outcomes. However, multiple variables and scenarios that influence the results still make difficult to obtain convincing recommendations.

METHODS

We performed a review of relevant available data in English regarding the use of synthetic meshes in contaminated abdominal wall surgery using the Medline database. Articles including patients undergoing ventral hernia in contaminated fields were included for analysis.

RESULTS

Most studies support the use of synthetic meshes for ventral hernia repair in contaminated fields, as they have shown lower recurrence rate and similar wound morbidity. Although no mesh seems ideal in this setting, most surgeons advocate for the use of reduced-in-weight polypropylene mesh. Sublay location of the prosthesis associated with complete fascial closure appears to offer better results in these patients. In addition, current evidence suggests that the use of prophylactic synthetic mesh when performing a stoma or for stoma reversal incisional hernias might be beneficial.

CONCLUSION

A better understanding of surgical site occurrences and its prevention, as well as the introduction of new reduced-in-weight meshes have allowed using synthetic meshes in a contaminated field. Although the use of mesh has indeed shown promising results in these patients, the surgical team should still balance pros and cons at the time of placing synthetics in contaminated fields.

Parastomal hernia after radical cystectomy with ileal conduit diversion: a narrative review

Radical cystectomy (RC) with ileal conduit urinary diversion has become a common surgical procedure. Stomal complications and particularly parastomal hernia (PH) are the most frequent complications and causes of reintervention after RC with ileal conduit urinary diversion. PH is usually asymptomatic. When PH increases in size and becomes symptomatic, it clearly impairs patients' quality of life in terms of physical limitation, mental distress and social interaction. The aim of this article was to review the current knowledge on PH after RC with ileal conduit urinary diversion, regarding its natural history, risk factors, prevention and surgical management. There is no strong recommendation on the ideal surgical technique for repair of PH after RC, but laparoscopic Sugarbaker or Sandwich techniques with non-absorbable meshes are emerging as the preferred modern means of PH repair. Techniques for prevention and repair of PH after RC need to be specifically evaluated in future prospective studies.

Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience

BACKGROUND

Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site.

METHOD

A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure.

RESULTS

A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group.

DISCUSSION

The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.

A semi-Markov model comparing the lifetime cost-effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing end colostomy creation for rectal cancer

AIM

Parastomal hernia (PSH) is a common problem following colostomy. Using prophylactic mesh during end colostomy creation may reduce PSH incidence, but concerns exist regarding the optimal type of mesh, potential long-term complications, and cost-effectiveness of its use. We evaluated the cost-effectiveness of mesh prophylaxis to prevent PSH in patients undergoing end colostomy creation for rectal cancer.

METHODS

We developed a decision-analytical model, stratified by rectal cancer stages I-IV, to estimate the lifetime costs, quality-adjusted life-years (QALYs) and net monetary benefits (NMBs) of synthetic, biologic and no mesh from a UK NHS perspective. We pooled the mesh-related relative risks of PSH from 13 randomised controlled trials (RCTs) and superimposed these on the baseline (no mesh) risk from a population-based cohort. Uncertainty was assessed in sensitivity analyses.

RESULTS

Synthetic mesh was less costly and more effective than biologic and no mesh to prevent PSH for all rectal cancer stages. At the willingness-to-pay threshold of £20,000/QALY, the incremental NMBs (95% CI) ranged between £1,706 (£1,692 to £1,720) (stage I) and £684 (£678 to £690) (stage IV) for synthetic versus no mesh, and £2,038 (£1,997 to £2,079) (stage I) and £1,671 (£1,653 to £1,689) (stage IV) for synthetic versus biologic mesh. Synthetic mesh was more cost-effective than no mesh unless the relative risk of PSH was ≥0.95 for stages I-III and ≥0.93 for stage IV. [Correction added on 05 October 2021 after first online publication: The estimation of health outcomes (QALYs) for all three interventions evaluated (synthetic mesh; biologic mesh; no mesh) have been corrected in this version.] CONCLUSIONS: Synthetic mesh was the most cost-effective strategy to prevent the formation of PSH in patients after end colostomy for any rectal cancer stage; however, conclusions are dependent on which subset of RCTs are considered to provide the most robust evidence.

Use of prophylactic mesh during initial stoma creation to prevent parastomal herniation: a systematic review and meta-analysis of randomised controlled trials

AIM

Parastomal hernia (PSH) is a common complication following stoma creation. Previous reviews found mesh reinforcement during initial stoma creation beneficial in reducing PSH incidence. Since then, several multicentre randomised controlled trials (RCTs) produced widely ranging results rendering previous findings debatable. This current review assessed whether combining the latest larger multicentre RCTs would alter the previous findings.

METHODS

The Cochrane Library, MEDLINE and Embase were searched from the respective dates of inception until 15 January 2021. RCTs were included if they compared mesh with no mesh during initial stoma creation in adult patients to prevent PSH. Included RCTs were summarised narratively and meta-analysed to estimate the relative risk (RR) of PSH incidence (primary analysis), peristomal complications and PSH repair (secondary analyses). Several subgroup analyses were performed, including mesh type (synthetic/biologic), surgical technique (open/laparoscopic) and mesh position (sublay/intraperitoneal).

RESULTS

Thirteen RCTs were included in the primary meta-analysis (1070 patients); PSH incidence was reduced in patients with mesh compared with patients without mesh at maximal follow-up (RR = 0.54; 95% CI 0.39-0.77; I²  = 67%; P < 0.01). The number of PSH repairs was fewer in patients who had mesh (RR = 0.63; 0.35-1.14; I²  = 6%; P = 0.39), with no difference in peristomal complications (RR = 0.96; 0.55-1.70; I²  = 0%; P = 0.71), comparing with no mesh. Subgroup analyses suggested that placing synthetic mesh using an open sublay technique might be more beneficial.

CONCLUSIONS

Prophylactic mesh reinforcement during initial stoma creation reduces PSH incidence and potentially its repair, without an increase in peristomal complications. However, substantial heterogeneity among included RCTs limits confidence in the results.

Abdominal wall complications after kidney transplantation: A clinical review

Introduction

Abdominal wall complications are common after kidney transplantation, and although they have a minor impact on patient and graft survival, they increase the patient's morbidity and may have an impact on quality of life. Abdominal wall complications have an overall incidence of 7.7–21%.

Methods

This review will explore the natural history of abdominal wall complications in the kidney transplant setting, with a special focus on wound dehiscence and incisional herni, with a particular emphasis on risk factors, clinical characteristics, and treatment.

Results

Many patient‐related risk factors have been suggested, including older age, obesity, and smoking, but kidney transplant recipients have an additional risk related to the use of immunosuppression. Wound dehiscence usually does not require surgical intervention. However, for deep dehiscence involving the fascial layer with concomitant infection, surgical treatment and/or negative pressure wound therapy may be required.

Conclusions

Incisional hernia (IH) may affect 1.1–18% of kidney transplant recipients. Most patients require surgical treatment, either open or laparoscopic. Mesh repair is considered the gold standard for the treatment of IH, since it is associated with a low rate of postoperative complications and an acceptable rate of recurrence. Biologic mesh could be an attractive alternative in patients with graft exposition or infection.

Urostomal ileal conduit complications in association with abdominal wall mesh implantation

OBJECTIVE

Parastomal hernia (PH) in association with an ileal conduit is a common complication that is difficult to treat. Mesh reinforcement has been suggested to improve outcomes; either as prophylaxis or for treatment of a parastomal hernia during abdominal wall reconstruction.

PATIENTS AND METHODS

A retrospective study was performed in consecutive patients subjected to mesh implantation between 2000 and 2016 having a concurrent or previous ileal conduit reconstruction. Postoperative and late urostomal complications, as well as hernia occurrence, were ascertained by a chart review of patients' records.

RESULTS

A total of 25 patients were included of whom 13 (52%) developed either a urostomal complication, a PH, or both. Complications were caused by mesh erosion in four patients, of which three were diagnosed more than five years after surgery. Four patients developed a urostomal stenosis. One out of eight patients with urostomal complications were subjected to a new ileal conduit reconstruction and another four to other types of revisional surgery.

CONCLUSIONS

Every second patient with an ileal conduit developed either a local urostomal complication, a PH, or both after abdominal wall mesh reconstruction. A careful and cautious attitude towards the use of mesh in patients with an ileal conduit is suggested.

Prophylactic funnel mesh to prevent parastomal hernia in permanent end colostomy: A retrospective cohort study

AIM

This study assessed the impact of a prophylactic, 3D funnel-shaped intraperitoneal mesh on the rate of parastomal hernia after abdominoperineal rectum resection with permanent end colostomy.

METHODS

Data from 76 patients receiving permanent end colostomy after abdominoperineal rectum resection between 2013 and 2018 were collected retrospectively. Occurrences of parastomal hernia and reoperation rate due to parastomal hernia in patients with and without a prophylactic mesh were compared by univariate, multivariate, and propensity score-adjusted analyses.

RESULTS

Twenty-two (28.9%) of the 76 included patients received a prophylactic mesh. The mean follow-up was 39.3 ± 23.8 months. Mesh implantation reduced the incidence of parastomal hernia to 9.1% (n = 2) compared to 42.6% (n = 23) in patients without a prophylactic mesh. The propensity score-adjusted hazard ratio (HR) was 0.14 (95% confidence interval (CI): 0.04-0.48, p = 0.001). No reoperations due to parastomal hernia were needed in patients who received a prophylactic mesh, while nine patients without mesh (16.7%) required parastomal hernia repair (HR = 0.09, 95% CI: 0.00-1.76, p = 0.015). Mesh implantation was not associated with increased short-term morbidity (Clavien-Dindo grade > 2, 31.8% vs. 40.7%, p = 0.468) or 30-day mortality (4.5% vs. 3.8%, p = 1.000).

CONCLUSIONS

Prophylactic implantation of a 3D funnel-shaped intraperitoneal mesh is a safe and effective method to prevent parastomal hernia in patients requiring permanent end colostomy. Mesh placement significantly reduces reoperations due to parastomal hernia.

Abdominal Oblique Internal and External Muscles Gap Colostomy for Lower Incidence of Parastomal Hernia and Higher Quality of Life: A Retrospective Cohort Study

BACKGROUND

Parastomal hernia and fecal incontinence cause severe distress to the rectal cancer patients with stoma after abdominoperineal resection. We attempted a new colostomy technique through the gap between the abdominal oblique internal and external muscles to prevent parastomal hernia and improve quality of life.

METHODS

This cohort study retrospectively examined clinical data from a total of 114 consecutive rectal cancer patients who underwent laparoscopic abdominoperineal resection in our center from March 2016 to March 2018 after propensity score matching. Group A included 57 patients who underwent colostomy through the gap between the abdominal oblique internal and oblique external muscles, while group B included 57 patients who underwent extraperitoneal colostomy. Patients' quality of life was evaluated using Fecal Incontinence Quality of Life (FIQL) Scale.

RESULTS

Group A had a lower incidence of parastomal hernia (0% vs. 15.7%, p = 0.004) and higher quality of life, especially in lifestyle, coping/behavior and embarrassment domains (all p values < 0.05) than group B both during the follow-up period. The incidence of other outcomes did not differ between the groups.

CONCLUSIONS

Colostomy through the gap between the abdominal oblique internal and oblique external muscle is a new technique showing both safety and effectiveness for preventing parastomal hernia and improving quality of life after laparoscopic abdominoperineal resection.

Prophylactic mesh placement at index permanent end colostomy creation to prevent parastomal hernia-an updated meta-analysis

BACKGROUND

Debate persists regarding the efficacy of prophylactic mesh insertion (PMI) at index permanent stoma creation to reduce the rate of parastomal hernia (PSH). This meta-analysis aimed to appraise all the latest evidence from newly published randomized controlled trials (RCTs) on PMI for PSH prevention.

METHODS

PubMed, EMBASE, and Cochrane databases were searched for relevant articles from inception until November 2020. All RCTs that reported on PMI at end colostomy creation with ≥ 12 months follow-up were included. The primary objective was the rate of clinical and radiological PSH while secondary objectives included number of PSH requiring repair and stoma (or mesh)-related complications. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed.

RESULTS

Eleven RCTs were included capturing 1097 patients. The mean (SD) age was 67.9 (±9.4) years. On random effects analysis, prophylactic mesh appeared to reduce the rate of both clinical (OR = 0.27, 95% CI = 0.12 to 0.61, p = 0.002) and radiological (OR = 0.39, 95% CI = 0.24 to 0.65, p = 0.0002) PSH. However, there was no difference in number of PSH requiring repair or stoma-related complications. On sensitivity analysis, when focusing on low-risk of bias studies, the benefit of prophylactic mesh in the retrorectus space was lost for both clinical (OR = 0.97, 95% CI = 0.62 to 1.51, p = 0.89) and radiological PSH (OR = 0.74, 95% CI = 0.46 to 1.18, p = 0.20).

CONCLUSION

PMI may reduce the rate of subsequent PSH. However, further studies are required to confirm these findings and to establish the optimal mesh position and shape before definite recommendations can be made.

Effectiveness of hybrid intraperitoneal mesh repair for paracolostomy hernia

Due to advances in medical science, the frequency of surgical interventions that once ended in end-stoma formation has decreased significantly. An ostomy is a life-saving surgery performed when there are no other options. Unfortunately, the number of patients with life-threatening conditions requiring colostomy or ileostomy is growing. A stoma in itself is a cause of social alienation; stoma-associated complications reduce the quality of life and debilitate the patient. The aim of this study was to assess the effectiveness of hybrid intraperitoneal mesh repair of paracolostomy hernia using a modified EUROQOL 5D-5L questionnaire. Sixty patients with paracolostomy hernias included in the study were divided in 2 groups (30 persons per group). The experimental group (10 (33%) men and 20 (67%) women) and the control group (11 (37%) men and 19 (63%) women) were comparable in terms of sex (р = 0.787) and age (66.5 (62.2; 72.0) years vs. 65.0 (61.25; 71.75) years, respectively; р = 0.246). Patients included in the control group underwent a classic Sugarbaker procedure; the experimental group underwent hybrid intraperitoneal mesh repair. The quality of life of the patients was evaluated before surgery and then 1 and 2 years after surgery using a modified EUROQOL 5D-5L questionnaire. Hybrid intraperitoneal mesh repair proved to be effective in the early and late postoperative periods. Based on the significant improvement of the patients’ quality of life after hybrid intraperitoneal mesh repair, we conclude that this technique is an effective surgical treatment for paracolostomy hernias.

Mini-invasive Surgery and Parastomal Hernia: Higher Frequency and No Prophylactic Mesh Effect

AIM

Parastomal hernia (PSH) is very common. Recent reports suggest increased frequency after laparoscopic stoma formation compared with open surgery. A retrospective chart review was designed to appraise the outcomes regarding PSH in open and in laparoscopic procedures.

MATERIALS AND METHODS

All patients operated by rectal resection and planned end-colostomy in the period from 2004 to 2018 were reviewed. A total of 70 open and 101 laparoscopic operations were identified. A modified retromuscular mesh application through the trephine was used for the prevention of PSH in 42% of patients in the laparoscopic group.

RESULTS

The median follow-up was 58 (1 to 167) months in the open group and 43 (0 to 153) months in the laparoscopic group. Patient characteristics were evenly distributed between the groups, except for more male patients and higher American Society of Anesthesiologists Score as well as higher rates of patients with neoadjuvant treatment and mesh prophylaxis, in the laparoscopic group. Clinical PSH occurrences were 2 (3%) in the open group and 18 (18%) in the laparoscopic group (P=0.00). Propensity-weighted analysis estimates increased odds ratio (OR) for PSH in the laparoscopic group [OR=11.8; 95% confidence interval (CI): 1.4-96.6]. PSH repair rates were 0 in the open group and 6/18 (33%) in the laparoscopic group. Mesh prophylaxis in the laparoscopic group did not influence PSH outcome (OR=1.4; 95% CI: 0.5-4.0). Computed tomography scans were assessable in 48 and 66 patients, with median follow-up timepoints of 42 and 30 months in the open and laparoscopic groups, respectively, and 8 (18%) and 21 patients (32%) were diagnosed with PSH. Computed tomography assessment implied an increased risk for PSH in laparoscopy (OR=3.5; 95% CI: 1.1-11.9). Aggregate of chart and computed tomography occurrence of PSH showed an equivalent hazard (OR=3.2; 95% CI: 1.1-9.5).

INTERPRETATIONS

Laparoscopic operations with stoma formation seem to have an increased rate of PSH in comparison with open operations and the results support previous claims. Retromuscular keyhole mesh placement may not be the ideal method of PSH prevention in laparoscopic stoma formation.

Meta-analysis and Systematic Review of the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia

OBJECTIVE

The primary endpoint of this meta-analysis was the PSH rate at 1 year of follow-up with or without the use of a mesh.

SUMMARY OF BACKGROUND DATA

European guidelines currently recommend the use of a mesh at the time of a stoma formation for the prevention of PSH. These recommendations are based on the RCT and meta-analyses published before 2017. More recently 2 large RCT found no benefit in the mesh group. We investigated whether these latest results could change the conclusion of a meta-analysis.

METHODS

We conducted a comprehensive literature search and analyzed RCT investigating the use of a mesh to prevent PSH formation. All studies including end colostomies were included in the qualitative analysis no matter the surgical technique or the type of mesh. All studies with a limited risk of bias and presenting with usable data were used in the quantitative analysis.

RESULTS

There is a large heterogeneity among the studies, in terms of position of the mesh, surgical technique, and diagnostic method for the PSH.No statistically significant difference was found on the PSH rate at 1 or 2 years between the mesh and non-mesh groups.

CONCLUSIONS

Based on this meta-analysis including the latest RCT on the prevention of PSH, the use of a mesh should not be recommended.

Stoma-related complications: a report from the Stoma-Const randomized controlled trial

AIM

The impact of construction techniques on the development of stoma complications is partly undiscovered. The aim of this paper was to report and analyse the impact of the three surgical techniques in a randomized controlled trial Stoma-Const on stoma-related complications as well as identifying risk factors and patient-reported stoma function as a planned secondary analysis.

METHODS

This was a randomized, multicenter trial where all patients scheduled to receive an end colostomy were invited to participate. Patients were randomized to one of three techniques for stoma construction; cruciate fascial incision, circular incision or prophylactic mesh. Stoma complications were assessed by a surgeon and stoma care nurses within 1 year postoperatively.

RESULTS

Two hundred and nine patients were randomized. Patient demographics were similar in all three groups. Data on stoma-related complications were available for analysis in 201 patients. A total of 127 patients (63%) developed some type of stoma complication within 1 year after surgery. The risk ratio (95% CI) for stoma complications was 0.93 (0.73; 1.2) between cruciate vs. circular incision groups and 1.02 (0.78; 1.34) between cruciate vs. mesh groups. There were no statistically significant differences between the groups regarding parastomal hernia rate and no risk factors could be identified.

CONCLUSION

This randomized trial confirmed a high prevalence of stoma-related complications but could not identify an impact of surgical technique or identify modifiable risk factors for stoma-related complications.

The Role of Mesh Implants in Surgical Treatment of Parastomal Hernia

A parastomal hernia is a common complication following stoma surgery. Due to the large number of hernial relapses and other complications, such as infections, adhesion to the intestines, or the formation of adhesions, the treatment of hernias is still a surgical challenge. The current standard for the preventive and causal treatment of parastomal hernias is to perform a procedure with the use of a mesh implant. Researchers are currently focusing on the analysis of many relevant options, including the type of mesh (synthetic, composite, or biological), the available surgical techniques (Sugarbaker’s, “keyhole”, or “sandwich”), the surgical approach used (open or laparoscopic), and the implant position (onlay, sublay, or intraperitoneal onlay mesh). Current surface modification methods and combinations of different materials are actively explored areas for the creation of biocompatible mesh implants with different properties on the visceral and parietal peritoneal side. It has been shown that placing the implant in the sublay and intraperitoneal onlay mesh positions and the use of a specially developed implant with a 3D structure are associated with a lower frequency of recurrences. It has been shown that the prophylactic use of a mesh during stoma formation significantly reduces the incidence of parastomal hernias and is becoming a standard method in medical practice.

Regulatory science for hernia mesh: Current status and future perspectives

Regulatory science for medical devices aims to develop new tools, standards and approaches to assess the safety, effectiveness, quality and performance of medical devices. In the field of biomaterials, hernia mesh is a class of implants that have been successfully translated to clinical applications. With a focus on hernia mesh and its regulatory science system, this paper collected and reviewed information on hernia mesh products and biomaterials in both Chinese and American markets. The current development of regulatory science for hernia mesh, including its regulations, standards, guidance documents and classification, and the scientific evaluation of its safety and effectiveness was first reported. Then the research prospect of regulatory science for hernia mesh was discussed. New methods for the preclinical animal study and new tools for the evaluation of the safety and effectiveness of hernia mesh, such as computational modeling, big data platform and evidence-based research, were assessed. By taking the regulatory science of hernia mesh as a case study, this review provided a research basis for developing a regulatory science system of implantable medical devices, furthering the systematic evaluation of the safety and effectiveness of medical devices for better regulatory decision-making. This was the first article reviewing the regulatory science of hernia mesh and biomaterial-based implants. It also proposed and explained the concepts of evidence-based regulatory science and technical review for the first time.

End Colostomy With or Without Mesh to Prevent a Parastomal Hernia (GRECCAR 7): A Prospective, Randomized, Double Blinded, Multicentre Trial

OBJECTIVE

To evaluate whether systematic mesh implantation upon primary colostomy creation was effective to prevent PSH.

SUMMARY OF BACKGROUND DATA

Previous randomized trials on prevention of PSH by mesh placement have shown contradictory results.

METHODS

This was a prospective, randomized controlled trial in 18 hospitals in France on patients aged ≥18 receiving a first colostomy for an indication other than infection. Participants were randomized by blocks of random size, stratified by center in a 1:1 ratio to colostomy with or without a synthetic, lightweight monofilament mesh. Patients and outcome assessors were blinded to patient group. The primary endpoint was clinically diagnosed PSH rate at 24 months of the intention-to-treat population. This trial was registered at ClinicalTrials.gov, number NCT01380860.

RESULTS

From November 2012 to October 2016, 200 patients were enrolled. Finally, 65 patients remained in the no mesh group (Group A) and 70 in the mesh group (Group B) at 24 months with the most common reason for drop-out being death (n = 41). At 24 months, PSH was clinically detected in 28 patients (28%) in Group A and 30 (31%) in Group B [P = 0.77, odds ratio = 1.15 95% confidence interval = (0.62;2.13)]. Stoma-related complications were reported in 32 Group A patients and 37 Group B patients, but no mesh infections. There were no deaths related to mesh insertion.

CONCLUSION

We failed to show efficiency of a prophylactic mesh on PSH rate. Placement of a mesh in a retro-muscular position with a central incision to allow colon passage cannot be recommended to prevent PSH. Optimization of mesh location and reinforcement material should be performed.

Short-term outcomes of parastomal hernia prophylaxis with Stapled Mesh stomA Reinforcement Technique (SMART) in permanent stomas

BACKGROUND

Parastomal hernias occur in 50-80% after stoma formation. Even with mesh repairs, recurrence can be as high as 33%. Stapled Mesh stomA Reinforcement Technique (SMART) places a prophylactic onlay mesh in the trephine during permanent stoma formation to prevent parastomal hernia. Our study aims to describe the short-term outcomes of SMART procedures.

METHODS

A prospective study of patients receiving the SMART procedure from 2015 to 2020 was conducted.

INCLUSION CRITERIA

non-Crohn's colorectal and urological surgery with permanent stoma formation. The SMART surgical technique incorporates a 70-mm circular piece of polypropylene mesh by stapling it to the muscular abdominal wall using a circular stapler, and attaching the edge of the mesh to the deep fascia.

RESULTS

Fifty patients had a total of 53 SMART procedures. Median follow-up was 27 months. Procedures included: 35 end colostomies, five end ileostomies, eight ileal urinary conduits and five double-barrelled wet colostomies. Four patients had parastomal hernia during follow-up. One was acute, on day 1, due to very large size of trephine, one in a double-barrelled wet stoma that was repaired laparoscopically, one had a stomal prolapse requiring revision at 3 years and one patient had early small bowel obstruction due to very small size of trephine requiring another surgery. There were no wound infections or mesh-related sepsis.

CONCLUSION

Symptomatic parastomal herniation occurred in 8% of the study population, and most complications were due to incorrect choice of stapled trephine diameter. Longer term follow-up is required to assess for problematic parastomal hernia.

Permanent end-colostomy parastomal hernia prevention using a novel three-dimensional mesh

PURPOSE

Prophylactic mesh placement has been proposed to reduce the high occurrence of parastomal hernia (PSH) after stoma formation.

METHODS

This is an observational study comparing two cohorts of patients: a mesh prophylaxis group (who received mesh prevention since introduction at our Institution) and a no mesh prophylaxis group (retrospectively selected from our historical series). Same exclusion criteria were applied for both groups. The study was conducted at a tertiary referral center for colorectal surgery. 43 patients were operated with mesh prophylaxis between May 2015 and may 2019. 45 patients underwent end-colostomy formation without prophylaxis between April 2011 and April 2015. The primary outcome measure was PSH development at 12-month follow up.

RESULTS

Demographic variables and risk factors for PSH were comparable between the two groups. There was no difference between the two cohorts in terms of operative time and main early postoperative outcomes. 37 patients completed the 12-month follow up in each group. PSH occurrence after 12-months was 11% in the mesh prophylaxis group and 54% in the no mesh prophylaxis group (p < 0.0001). There were no differences in long-term complications. 5% of patients who received mesh prophylaxis underwent emergency surgery for bowel occlusion at 7 and 10 months after surgery, with partial or complete mesh removal. At multivariate analysis, mesh prophylaxis was a protective factor for PSH development at 12 months (p < 0.0001).

CONCLUSIONS

Prophylactic intraperitoneal mesh placement appears to be effective in preventing PSH.

Preventing Parastomal Hernia After Ileal Conduit by the Use of a Prophylactic Mesh: A Randomised Study

BACKGROUND

Parastomal hernia (PSH) after urinary diversion with ileal conduit is frequently a clinical problem.

OBJECTIVE

To investigate whether a prophylactic lightweight mesh in the sublay position can reduce the cumulative incidence of PSH after open cystectomy with ileal conduit.

DESIGN, SETTING, AND PARTICIPANTS

From 2012 to 2017, we randomised 242 patients 1:1 to conventional stoma construction (n = 124) or prophylactic mesh (n = 118) at three Swedish hospitals (ISRCTN 95093825).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was clinical PSH, and secondary endpoints were radiological PSH assessed in prone position with the stoma in the centre of a ring, parastomal bulging, and complications from the mesh.

RESULTS AND LIMITATIONS

Within 24 mo, 20/89 (23%) patients in the control arm and 10/92 (11%) in the intervention arm had developed a clinical PSH (p = 0.06) after a median follow-up of 3 yr, corresponding to a hazard ratio of 0.45 (confidence interval 0.24-0.86, p = 0.02) in the intervention arm. The proportions of radiological PSHs within 24 mo were 22/89 (25%) and 17/92 (19%) in the two study arms. During follow-up, five patients in the control arm and two in the intervention arm were operated for PSH. The median operating time was 50 min longer in patients receiving a mesh. No differences were noted in proportions of Clavien-Dindo complications at 90 d postoperatively or in complications related to the mesh during follow-up.

CONCLUSIONS

Prophylactic implantation of a lightweight mesh in the sublay position decreases the risk of PSH when constructing an ileal conduit without increasing the risk of complications related to the mesh. The median surgical time is prolonged by mesh implantation.

PATIENT SUMMARY

In this randomised report, we looked at the risk of parastomal hernia after cystectomy and urinary diversion with ileal conduit with or without the use of a prophylactic mesh. We conclude that such a prophylactic measure decreased the occurrence of parastomal hernias, with only a slight increase in operating time and no added risk of complications related to the mesh.

Quality Assessment and Risk of Bias of Systematic Reviews of Prophylactic Mesh for Parastomal Hernia Prevention Using AMSTAR and ROBIS Tools

BACKGROUND

Systematic reviews play a crucial role in clinical decision making and resource allocation and are expected to be unbiased and consistent. The aim of this study is a review of systematic reviews on the use of prophylactic mesh to prevent parastomal hernia (PH) formation using ROBIS and AMSTAR tools to assess the risk of bias and methodological quality.

METHODS

We included systematic reviews with or without meta-analysis of which the objective was to assess the use of a prophylactic mesh to prevent PH. A systematic search of the literature in five databases from inception until December 2017 was conducted. For each systematic review, methodologic quality and risk of bias were assessed using the AMSTAR and ROBIS tools, respectively. We estimated the inter-rater reliability for individual domains and for the overall methodological quality and risk of bias using Fleiss' k.

RESULTS

We identified 14 systematic reviews that met the inclusion criteria. Using the AMSTAR scale with a cutoff value, six reviews showed high methodologic quality and eight were of low quality. Using the ROBIS tool, the overall risk of bias was low in 50% of the reviews analyzed. In the remaining studies, the risk of bias was unclear.

CONCLUSIONS

The global evidence in favor of the use of a prophylactic mesh for preventing PH is not uniform regarding quality and risk of bias. Surgeons cannot be equally confident in the results of all systematic reviews published on this topic.

Parastomal gallbladder herniation: A case report and review of the literature

•

Gallbladder herniation is a rare complication of a parastomal hernia, affecting primarily elderly females.

•

For patients with parastomal swelling and pain gallbladder herniation should be included in the differential diagnosis.

•

Elderly patients with multiple comorbidities may benefit from a conservative approach instead of surgery.

•

The use of prophylactic mesh when creating a permanent end colostomy reduces the rate of parastomal hernias.

Introduction

Parastomal hernia is a common complication of patients living with an enterostomy. However, a parastomal hernia involving the gallbladder is a rare condition with only eight cases documented in the literature.

Presentation of case

We report the case of a 69-year old female who underwent an open right hemicolectomy with creation of a colostomy and terminal ileostomy. She presented with parastomal swelling and pain 16 months later. A computed tomography scan revealed a parastomal herniation of the gallbladder. We elected to proceed with a cholecystectomy and hernia repair, the patient was asymptomatic at her last follow-up.

Discussion

A systematic search of the literature found eight previously published cases. This condition primarily affects elderly females. Five patients were treated surgically and three conservatively, all with a favorable outcome. In frail patients without complicating factors, a conservative treatment approach with surveillance may be safe. We chose a surgical approach due to the symptomatic nature of the presentation and the gallstone containing hernia. This is the first case of a parastomal gallbladder herniation containing a large gallstone.

Conclusion

This report should help broadening the physician’s differential diagnosis in dealing with patients with symptomatic parastomal hernias and provide an example for diagnosis and management of this complication.

Do North American colorectal surgeons use mesh to prevent parastomal hernia? A survey of current attitudes and practice

Background

The use of prophylactic mesh in end colostomy procedures has been shown to reduce the rate of parastomal hernia. However, the degree to which the practice has been adopted clinically remains unknown. We conducted a study to evaluate the current opinions and practice patterns of Canadian and US colorectal surgeons with regard to the use of prophylactic mesh in end colostomy.

Methods

Between May and July 2017, we conducted an internet-based survey of colorectal surgeons in Canada and the United States (selected at random). Using a questionnaire designed and tested for this study, we assessed the rate of mesh use, types of mesh and placement techniques, and perceived barriers and facilitators associated with the practice.

Results

Forty-eight (51.6%) of 93 invited Canadian surgeons and 253 (16.6%) of 1521 invited US surgeons responded (overall response rate 18.6%). Of the 301 respondents, 32 (10.6%) were currently using mesh, 32 (10.6%) had previously used mesh, and 237 (78.7%) had never used mesh. Of 29 respondents currently using mesh, 12 (41.4%) used it only in selected patients; the majority used a sublay technique (20 [69.0%]) and biologic mesh (17 [58.6%]). Most respondents agreed that parastomal hernias are common and negatively affect quality of life; however, there remained concerns about evidence quality and the perceived risk associated with mesh among those who had never or had previously used mesh.

Conclusion

Prophylactic mesh placement remains relatively uncommon; when used, biologic mesh was the most common type. Many surgeons were not convinced of the safety or efficacy of prophylactic mesh placement.

Prospective, Randomized Study on the Use of Prosthetic Mesh to Prevent a Parastomal Hernia in a Permanent Colostomy: Results of a Long-term Follow-up

BACKGROUND

Parastomal hernias are common with permanent colostomies and prone to complications. The short-term results of trials of parastomal hernia prevention are widely published, but long-term results are scarce.

OBJECTIVE

The aim of the study is to detect the long-term effects and safety of preventive intra-abdominal parastomal mesh.

DESIGN

This is a long-term follow-up of a previous prospective randomized, controlled multicenter trial.

SETTINGS

This study was conducted at 2 university hospitals and 3 central hospitals in Finland.

PATIENTS

Patients who had a laparoscopic abdominoperineal resection for rectal cancer between 2010 and 2013 were included in the study and invited for a follow-up visit.

MAIN OUTCOME MEASURES

The primary outcomes measured were clinical and radiological parastomal hernias.

RESULTS

Twenty subjects in the mesh group and 15 in the control group attended the follow-up visit with a median follow-up period of 65 (25th-75th percentiles, 49-91) months. A clinically detectable parastomal hernia was present in 4 of 20 (20.0%) and 5 of 15 (33.3%) subjects in the mesh and control groups (p = 0.45). A radiological parastomal hernia was present in 9 of 19 (45.0%) subjects in the mesh group and 7 of 12 (58.3%) subjects in the control group (p = 0.72). However, when all subjects (n = 70, 1:1) who attended the 12-month follow-up were screened for long-term results according to register data, 9 of 35 (25.9%) subjects in the mesh group and 16 of 35 (45.6%) subjects in control group were diagnosed with a parastomal hernia during the follow-up period (p = 0.10). In addition, only 1 of 35 (2.7%) subjects in the mesh group but 6 of 35 (17.1%) subjects in the control group underwent a parastomal hernia operation during the long-term follow-up (p = 0.030).

LIMITATIONS

The study is limited by the small number of patients.

CONCLUSION

Prophylactic intra-abdominal keyhole mesh did not decrease the rate of clinically detectable hernias but reduced the need for the surgical repair of parastomal hernias. Further trials are needed to identify a more efficient method to prevent parastomal hernias. See Video Abstract at http://links.lww.com/DCR/B171.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov. Identifier: NCT02368873. ESTUDIO PROSPECTIVO ALEATORIZADO SOBRE EL USO DE MALLA PROTÉSICA PARA PREVENIR UNA HERNIA PARAESTOMAL EN UNA COLOSTOMÍA PERMANENTE: RESULTADOS DE UN SEGUIMIENTO A LARGO PLAZO: PREVENCIÓN DE HERNIA PARAESTOMAL, NEOPLASIA COLORRECTAL/ANAL: Las hernias paraestomales son comunes con colostomías permanentes y son propensas a complicaciones. Los resultados a corto plazo de los ensayos sobre la prevención de la hernia parastomal se publican ampliamente, pero los resultados a largo plazo son escasos.El objetivo del estudio es detectar los efectos a largo plazo y la seguridad de la malla parastomal intraabdominal preventiva.Este es un seguimiento a largo plazo de un estudio aleatorizado prospectivo, controlado y multicentrico previo.Este estudio se realizó en dos hospitales universitarios y tres hospitales centrales en Finlandia.Los pacientes que se sometieron a una resección abdominoperineal laparoscópica por cáncer de recto 2010-2013 fueron incluidos en el estudio e invitados a una visita de seguimiento.Hernias parastomales clínicas y radiológicas.Veinte sujetos en el grupo de malla y 15 en el grupo control asistieron a la visita de seguimiento con una mediana de seguimiento de 65 meses (25-75 ° percentil 49-91). Una hernia paraestomal clínicamente detectable estuvo presente en 4/20 (20.0%) y 5/15 (33.3%) en los grupos de malla y control, respectivamente (p = 0.45). Una hernia parastomal radiológica estuvo presente en 9/19 (45.0%) en el grupo de malla y 7/12 (58.3%) en el grupo de control (p = 0.72). Sin embargo, cuando todos los sujetos (n = 70, 1: 1) que asistieron a los 12 meses de seguimiento fueron evaluados para obtener resultados a largo plazo de acuerdo con los datos del registro, 9/35 (25.9%) sujetos en el grupo de malla y 16/35 (45,6%) sujetos en el grupo control fueron diagnosticados con una hernia paraestomal durante el período de seguimiento (p = 0,10). Además, solo 1/35 (2.7%) en el grupo de malla pero 6/35 (17.1%) en el grupo control se sometieron a una operación de hernia paraestomal durante el seguimiento a largo plazo (p = 0.030).El estudio está limitado por un pequeño número de pacientes.La malla intra-abdominal profiláctica en ojo de cerradura no disminuyó la tasa de hernias clínicamente detectables, pero redujo la necesidad de la reparación quirúrgica de las hernias paraestomales. Se necesitan ensayos adicionales para identificar un método más eficiente para prevenir las hernias parastomales. Vea el resumen del video en http://links.lww.com/DCR/B171. (Traducción-Dr. Gonzalo Hagerman).NCT02368873.

Prophylactic mesh augmentation using permanent synthetic mesh: outcomes of keyhole and Stapled Ostomy Reinforcement with Retromuscular Mesh techniques

INTRODUCTION

Parastomal hernias (PSH) are the most common complication of stoma creation and can cause significant morbidity. We present a consecutive series of patients receiving prophylactic mesh augmentation (PMA) for prevention of PSH.

METHODS

This retrospective review evaluates the efficacy and outcomes of PMA for PSH prevention, and retrospectively compares traditional keyhole PMA (tPMA) (n = 28) with a prophylactic Stapled Ostomy Reinforcement with Retromuscular Mesh technique (pSTORRM) (n = 24).

RESULTS

PMA was performed in 52 cases between January 2015 and July 2018. All cases used a large-pore, non-coated, mid-weight polypropylene mesh placed in the retrorectus space. With a median follow-up of 16 mos, parastomal hernia was confirmed in 11.5% (n = 6), 5 of whom were symptomatic. patient-reported outcomes (PRO) indicated 6 additional patients with symptoms associated with PSH without clinical or radiographic confirmation. Patients had similar comorbidities and operative characteristics between tPMA and pSTORRM techniques, and no difference in a median follow-up. pSTORRM patients had fewer surgical site infections (8.3 vs 32.1%; p = 0.046) and occurrences (12.5 vs 46.4%; p = 0.015), and lower rate of PSH, though not statistically significant (4.2 vs 17.9%; p = 0.195).

CONCLUSION

Permanent synthetic mesh placed as a sublay in the retromuscular space is safe and appears to decrease the risk of PSH formation after the creation of permanent stomas. A stapled technique may provide advantages over a traditional keyhole technique.

Is mesh always necessary in every small umbilical hernia repair? Comparison of standardized primary sutured versus patch repair: retrospective cohort study

Purpose

A retrospective analysis was carried out to compare the results of patch repair using ready-made, synthetic mesh (PR) and sutured repair (SR) based on standard protocols. The accumulated recurrence rate was accepted as the primary outcome. Pain at rest and during exercise, cosmetic effect and treatment satisfaction were chosen as the secondary endpoints.

Methods

Adult patients after elective, open surgical repair of a single, primary umbilical hernia < 2 cm in diameter were included. Patients with incarceration or strangulation, after previous umbilical hernia repair or other abdominal surgical interventions were excluded. In the SR group, single-layer sutures were placed using the short-stitch technique. In PR group, a 6.3-mm ready-made Parietene Ventral Patch (Medtronic) was used.

Results

161 patients (104 in PR and 57 in SR groups) were included in the study (22 months follow-up). Nine recurrences were observed [six in PR (5.8%) and three in SR group (5.2%)]. In PR group, three patients (2.9%) reported complaints at rest and none in SR group, while 18 patients (17.3%) in PR group reported pain during exercises and 7 (12.3%) in SR group.

Conclusion

For the smallest umbilical hernias, the use of dense fascia suturing (short-stitch technique) may be an effective alternative to patch repair techniques in patients with no additional risk factors for recurrence. The mesh patch repair method is associated with a significantly higher risk of postsurgical pain. Diastasis recti is a factor favoring umbilical hernia recurrence after both pure tissue repair and patch repair.

Current Management of Intestinal Stomas and Their Complications

Inappropriate stoma site, improper management of stoma, and stoma complications lead to diminished quality of life of ostomates. Healthcare professionals involved in stoma creation and/or care should have the fundamental and updated knowledge of the management of stomas and their complications. This review article consists of the following major sections: principles of perioperative patient management, early complications, and late complications. In the “principles of perioperative patient management” section, the current concepts and trends in preoperative education, stoma site marking, postoperative education, and patient educational resources are discussed. In the “early complications” section, we have focused on the etiology and current management of ischemia/necrosis, fluid and electrolyte imbalances, mucocutaneous separation, and retraction. In the “late complications” section, we have focused on the etiology and current management of parastomal hernia, stoma prolapse, parastomal varices, and pyoderma gangrenosum. Pre- and postoperative patient education facilitates the patient's independence in stoma care and resumption of normal activities. Healthcare providers should have basic skills and updated knowledge on the management of stomas and complications of stomas, to act as the first crisis manager for ostomates.

Use of Prophylactic Mesh When Creating a Colostomy Does Not Prevent Parastomal Hernia: A Randomized Controlled Trial-STOMAMESH

OBJECTIVE

The aim of this study was to determine whether parastomal hernia (PSH) rate can be reduced by using synthetic mesh in the sublay position when constructing permanent end colostomy. The secondary aim was to investigate possible side-effects of the mesh.

BACKGROUND

Prevention of PSH is important as it often causes discomfort and leakage from stoma dressing. Different methods of prevention have been tried, including several mesh techniques. The incidence of PSH is high; up to 78%.

METHODS

Randomized controlled double-blinded multicenter trial. Patients undergoing open colorectal surgery, including creation of a permanent end colostomy, were randomized into 2 groups, with and without mesh. A lightweight polypropylene mesh was placed around the colostomy in the sublay position. Follow up after 1 month and 1 year. Computerized tomography and clinical examination were used to detect PSH at the 1-year follow up. Data were analyzed on an intention-to-treat basis.

RESULTS

After 1 year, 211 of 232 patients underwent clinical examination and 198 radiologic assessments. Operation time was 36 minutes longer in the mesh arm. No difference in rate of PSH was revealed in the analyses of clinical (P = 0.866) and radiologic (P = 0.748) data. There was no significant difference in perioperative complications.

CONCLUSIONS

The use of reinforcing mesh does not alter the rate of PSH. No difference in complication rate was seen between the 2 arms. Based on these results, the prophylactic use of mesh to prevent PSH cannot be recommended.

Chimney Trial: study protocol for a randomized controlled trial

BACKGROUND

Parastomal hernias (PSHs) are common, troubling the lives of people with permanent colostomy. In previous studies, retromuscular keyhole mesh placement has been the most-used technique for PSH prevention but results have been controversial. Additionally, surgical treatment of PSHs is associated with a high rate of complications and recurrences. Therefore, it is crucial to find the most effective way to prevent PSHs in the first place without an increased risk of complications. Due to a lack of adequate research, there is no clear evidence or recommendations on which mesh or technique is best to prevent PSHs.

METHODS/DESIGN

The Chimney Trial is a Nordic, prospective, randomized controlled, multicenter trial designed to compare the feasibility and the potential benefits of specifically designed, intra-abdominal onlay mesh (DynaMesh®-Parastomal, FEG Textiltechnik GmbH, Aachen, Germany) against controls with permanent colostomy without mesh. The primary outcome of the Chimney Trial is the incidence of a PSH detected by a computerized tomography (CT) scan at 12-month follow-up. Secondary outcomes are the rate of clinically detected PSHs, surgical-site infection as defined by the Centers for Disease Control and Prevention (CDC), complications as defined by the Clavien-Dindo classification, the reoperation rate, operative time, length of stay, quality of life as measured by the RAND-36 survey and colostomy impact score, and both direct and indirect costs. For each group, 102 patients were enrolled at attending hospitals and randomized at a ratio of 1:1 by browser-based software to receive a preventive mesh or a conventional colostomy without a mesh. Patients will be followed for 1 month and at 1, 3, and 5 years after the operation for long-term results and complications.

DISCUSSION

The Chimney Trial aims to provide level-I evidence on PSH prevention.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03799939. Registered on 10 January 2019.

Prevention of parastomal hernia after abdominoperineal excision with a prophylactic three-dimensional funnel mesh

AIM

A prophylactic three-dimensional (3D) funnel mesh using the keyhole technique (intraperitoneal onlay mesh position) in abdominoperineal excision (APR) may significantly decrease the parastomal hernia (PSH) index without increasing morbidity. The aim of this retrospective observational study was to analyse the incidence of PSH and postoperative complications in patients who underwent permanent colostomy with the use of a prophylactic 3D preformed mesh compared with patients without a mesh.

METHOD

Patients who underwent an end-colostomy after APR for primary or recurrent rectal cancer in a colorectal surgery unit were divided into two groups: group 1 without a prophylactic mesh and group 2 with a prophylactic synthetic mesh. The main end-point was to analyse the incidence of PSH after a median follow-up of 2.8 years.

RESULTS

One hundred and ten patients (64 in group 1 and 46 in group 2, without significant clinical differences) underwent a permanent colostomy after APR. In group 1 70.3% developed a PSH, compared with 13% in group 2 (P < 0.001). Age (especially for patients ≥ 75 years) represented a significant risk factor for PSH. There were no differences in postoperative complications between the groups.

CONCLUSION

A prophylactic parastomal 3D mesh using the keyhole technique may reduce the incidence of PSH after permanent colostomy without an increase in postoperative complications.